Textbook of Natural Medicine

Arnold S. Relman, M.D.
January 9, 2001

This two-volume textbook, published in a second edition in
1999, is edited by two naturopaths -- one the president, and the
other a member of the faculty of Bastyr University, which is the
leading school of naturopathic medicine in the country. The textbook
has over 1,600 pages and 57 contributors (most of whom practice
and/or teach naturopathic medicine), and it purports to provide
"well-documented standards of practice for natural medicine."
I therefore take it to be an up-to-date summary of what is taught
about the practice of naturopathic medicine and how its practitioners
are expected to provide care for the patients who consult them.

Among the criteria we have adopted for deciding whether a complementary
and alternative ("CAM") practice should be licensed
by the State are: (a) evidence that the practice "confers
measurable benefits" to those who use it (Criterion #2),
and (b) evidence that the use of "some or all of the modalities
within a practice that fall within the accepted standards of the
practice may result in direct patient harm" (Criterion #5).
A close reading of this textbook should provide some answers to
these crucial questions about the potential benefit and harm of
naturopathic practices as currently taught.

I borrowed a copy of the Textbook of Natural Medicine
(the "Textbook") and studied it carefully over a period
of several days in an attempt to answer these questions. My conclusion
is that the licensing of naturopathic medical practitioners as
independent providers of primary health care would endanger the
health and safety of the public and would not result in health
benefits commensurate with its risks. There is abundant evidence
in the Textbook to support this conclusion, but I summarize below
only a few of the most problematic examples of the deficiencies
and dangers in naturopathic practices.

1) The textbook describes the diagnosis and treatment of only
70 "specific health problems," and they are simply listed
in alphabetical order, without regard to the nature of the condition
or the organ(s) involved. In comparison, standard textbooks of
conventional medicine provide a much more rational and systematic
presentation that includes hundreds of disease conditions and
describes them in much greater depth and detail. The Textbook
includes in its 70 chapters on specific diseases nothing about
cancer, diseases of the blood (including leukemias and anemias),
nothing about heart attacks or serious abnormal rhythms of the
heart (such as atrial fibrillation), and virtually nothing about
kidney diseases, chronic obstructive pulmonary disease, cirrhosis
of the liver, or about many common and serious infections such
as pulmonary tuberculosis, malaria, syphilis, meningitis, encephalitis
or bacterial endocarditis. Lacking adequate education about these
diseases, naturopathic practitioners might fail to diagnose them
in a timely fashion or delay in referring patients for appropriate
medical treatment,

2) Many of the treatments recommended in the Textbook for the
70 diseases are not likely to be effective, and treatments
proven to be effective are often totally ignored. This could endanger
the health and safety of patients with serious diseases
who relied solely on care from a naturopathic practitioner. As
explained in the Textbook, naturopathy objects to the use of pharmaceutical
agents and depends instead an the use of herbal or "natural"
remedies of unproven value. Here are some examples of common,
serious diseases that are dangerously mistreated in the naturopathic
Textbook:

A) The chapter on the treatment of anginal (coronary artery)
heart disease does not even mention the use of nitrates, beta-blockers
or calcium-channel blockers -- all of which are standard, effective,
FDA-approved treatment for this condition. Failure to use one
or more of these agents in the treatment of severe angina would
probably be considered medical malpractice. There is no mention
of "statin" drugs to lower cholesterol and prevent
further progression of coronary heart disease. The use of angioplasty
or bypass surgery for patients unresponsive to pharmacologic
therapy is dismissed. "Chelation" -- a totally irrational
and unproven form of treatment -- is discussed favorably. However,
at the end of this chapter, it is stated that "patients
with unstable angina pectoris . . . should be hospitalized",
thus tacitly admitting that naturopathic methods may be ineffective
and that serious cases may require medical or surgical treatment
found only in hospitals.

B) The chapter on congestive heart failure recommends unproven
nutritional supplements, but says nothing about the standard
(and usually effective) treatment. with diuretics and ACE-inhibitors,
which have been shown to give comfort to, and prolong, the lives
of these patients, It does, however, admit that "In later
stages, adjunct (prescription) drug therapy is Usually necessary",
but gives no details,

C) The chapter on high blood pressure says nothing about the
diagnostic work up that is often needed to rule out certain curable
causes (such as certain diseases of the adrenal gland, or obstruction
in the aorta or the renal arteries). It recommends diet lifestyle
changes and the use of herbs but admits that severe cases unresponsive
to these "natural" measures may require treatment with
pharmaceuticals (presumably under the management of a conventional
medical doctor). However, it ends with the dangerous advice that
once control of high blood pressure has been achieved with drugs,
the naturopathic physician should have the patient "taper
off " the medications. For some such patients, a reduction
in medication risks sudden resurgence of severe hypertension
and the possibility of a stroke or heart attack. Most patients
with severe hypertension need to remain on medication indefinitely,
or for many years.

D) The chapter on diabetes says very little about the use
of insulin, nothing about oral hypoglycemic drugs, and nothing
about the diagnosis, prevention or treatment of diabetic acidosis--
except to warn that it is a medical emergency that will require
hospitalization,

E) The chapter on epilepsy says nothing about the use of anti-epileptic
drugs, without which many cases simply could not be adequately
controlled. Uncontrolled epilepsy is dangerous.

F) The chapter on HIV infection and AIDS advocates various
types of herbal and "natural" remedies but gives no
information about conventional drug therapy. Although it is admitted
that no clinical studies have yet demonstrated the effectiveness
of naturopathic medical care in HIV infection when used alone,
or even as a supplement to conventional medical treatment, the
chapter nevertheless ends with this advice: "We urge physicians
to apply the principles of naturopathic medicine in the care
of their HIV positive patients." As if this neglect of the
proven life-prolonging value of anti-viral pharmacotherapy were
not shocking enough, the chapter also fails to recommend drug
treatment of pregnant women with HIV infections, which is standard
practice for the prevention of HIV transmission to the newborn.
Neglect of such treatment would surely be considered malpractice
in the medical profession.

G) The chapter on the treatment of asthma is also seriously
deficient because it says nothing about the use of bronchodilator
drugs, or drugs that block the allergic response in the lining
of the respiratory passages, or about the short-term use of adrenal
steroids for emergency cases. These are all well-established
treatments for asthma; and it is difficult to imagine how serious
cases could be managed without them. However, the Textbook advises
naturopathic physicians to refer patients with acute asthmatic
attacks to a hospital emergency room. This acknowledging that
naturopathic remedies may not work and that seriously ill patients
will need treatment by conventional medical methods. But this
advice is also deficient in that it fails to mention that appropriate
medical treatment could prevent the onset of attacks that require
emergency care.

3) As already noted, naturopathic teaching (as exemplified
in the Textbook) claims that "natural" herbal remedies
are generally superior to pharmaceuticals in the treatment of
most diseases -- despite the fact that the FDA forbids the manufacturers
of herbal preparations and dietary supplements from making therapeutic
claims. The textbook nevertheless devotes a large section to herbs
and dietary supplements in which many such claims are made, often
with little or no credible supporting evidence in the peer-reviewed
scientific literature. At the same time, the Textbook omits entirely
(or mentions only in passing) the use of many standard, proven
pharmaceuticals that modern medicine has found useful or even
essential in the treatment of serious diseases. For example:

Antibiotics are given only cursory consideration and often
mentioned only as a last resort.

Nothing is said about the antibiotic treatment of syphilis
tuberculosis or meningitis.

Chemotherapeutic agents for cancer are dismissed despite
the fact that they are known to be effective in certain types
of tumors and in leukemias.

There is no mention of the use of anticoagulants (blood-thinners)
in the treatment of blood clots or their use to prevent embolic
strokes in patients with atrial fibrillation. (These diseases
are not even mentioned.)

There is no mention of diuretic drugs that are sometimes
absolutely essential in the treatment of edema due to heart failure
or kidney disease.

Perhaps most disturbing of all, there is no mention of opioid
drugs in the treatment of intractable pain. Morphine and its derivatives
are often essential for the relief of patients in the terminal
stages of cancer. It is almost incomprehensible that nowhere in
the numerous discussions of the management of pain by a great
variety of "natural" methods is there a reference to
the use of morphine or other analgesic drugs. Obviously, as any
experienced physician knows, there are alternatives to drugs that
may help -- particularly when pain is mild, moderate or only intermittent.
But in advanced cancer, morphine is often the only way to afford
relief, and it seems remarkable that the Textbook should omit
such an essential form of treatment.

Primary care practitioners whose education does not include
the use of prescription drugs simply cannot be expected to provide
effective and safe care for many serious conditions they are likely
to encounter. While it is true that unnecessary or inappropriate
use of drugs is harmful, and that even proper usage of drugs can
sometimes cause serious reactions, there can be no doubt that
on balance prescription drugs have been enormously beneficial,
and that drugs will be even more important in the future. The
anti-pharmaceutical bias of naturopathic education (as illustrated
in the Textbook) therefore poses real risks for patients who rely
on naturopaths for the management of their illnesses. Without
prompt and appropriate drug therapy many patients with serious
diseases will die.

I recognize that there are probably large variations in philosophy
and medical education among naturopathic practitioners. Some may
practice more prudently than others and may use conventional medical
treatments more frequently and work more closely with conventional
medical practitioners. But we should make public policy decisions
based on the standards of practice that are being taught, not
on our opinions about individual practitioners. Judging by the
standards of practice presented in the Textbook, it seems clear
that the risks to many sick patients seeking care from the average
naturopathic practitioner would far outweigh any possible benefits.

____________________

Dr. Relman is Emeritus Professor of Medicine and of Social
Medicine, Harvard Medical School; Editor-in-Chief Emeritus of
The New England Journal of Medicine; and a member of the
Massachusetts Board of Registration in Medicine (BORM). He prepared
this report while serving as BORM's representative to the Special
Legislative Commission on Complementary and Alternative Medical
Practitioners, an ad hoc group formed to provide advice to the
Massachusetts legislature.